SAN DIEGO — The American Diabetes Association said Sunday that all adults with type 2 diabetes or prediabetes should be screened for nonalcoholic fatty liver disease, a condition that is becoming more common and can lead to serious liver damage.
There are no approved drugs for the disease, but among the available diabetes drugs, the ADA has singled out GLP-1 treatments as an option doctors might consider, according to recommendations published at the annual ADA conference.
GLP-1 treatments, such as Ozempic and Mounjaro, are a class of drugs that have become widely popular for their efficacy not only in lowering blood sugar, but also in reducing weight. Drug companies have begun to study them in liver disease, and while some studies have shown they may provide some benefits, they have not yet been shown to improve harmful liver scarring.
The ADA published recommendations on the disease because “we realized that this is becoming such a pervasive problem,” said Robert Gabbay, the ADA’s chief scientific and medical officer. “In many ways, type 2 diabetes and obesity are becoming the leading causes of liver disease, and that’s not really on the radar of people thinking about diabetes.”
Non-alcoholic fatty liver disease, which occurs when excess fat builds up in the liver estimated to affect about 24% of American adults. A rarer, more serious form called non-alcoholic steatohepatitis or NASH, which involves inflammation and scarring of the liver, has become one of the leading causes of liver transplant and liver cancer.
Although the condition is becoming more common, there are no medications approved to treat it. Just last week, the Food and Drug Administration rejected a NASH treatment from Intercept Pharmaceuticals after agency advisers raised safety concerns.
In the new recommendations, the ADA said all diabetes patients should be screened with what’s known as a fibrosis-4 index, which is calculated based on age and standard blood measurements of ALT, AST and platelet counts.
People with a high index should have further tests such as liver stiffness measurement or the enhanced liver fibrosis test. If they are determined to be at high risk for liver scarring called fibrosis, they should be referred to a gastroenterologist or hepatologist, the ADA said.
Once patients are diagnosed with the disease, doctors should recommend that patients lose weight through lifestyle changes and consider prescribing a GLP-1 drug, the ADA said. The group also suggested pioglitazone, an older diabetes drug that some studies have shown may help with aspects of the disease.
While other diabetes drugs can still be used to lower blood sugar, there’s a lack of evidence that they help with fatty liver disease, according to the ADA.
There are also still limited data on the efficacy of GLP-1s in fatty liver disease. A process of semaglutide, the active ingredient in Ozempic, showed that the drug was associated with a higher degree of NASH resolution, but did not significantly improve liver scarring — a key factor that regulators consider when evaluating drugs for the liver disease.
There are also other drugs in the pipeline for NASH that may prove more effective than GLP-1s. A recent small study found that an experimental drug from Akero Therapeutics combined with a GLP-1 led to less liver fat and improved markers of liver scarring compared to a GLP-1 alone.
However, newer versions of GLP-1 drugs under development may show more promise against fatty liver disease. Merck this week presented data showing that its experimental drug – which targets not only the GLP-1 hormone, but also the glucagon hormone – led to greater reductions in liver fat compared to semaglutide. Boehringer Ingelheim is also testing a drug that targets GLP-1 and glucagon in NASH patients.